J.J. García

Procalcitonin in pediatric emergency departments for the early diagnosis of invasive bacterial infections in febrile infants: results of a multicenter study and utility of a rapid qualitative test for this marker

Background. Procalcitonin (PCT) is a potentially useful marker in pediatric Emergency Departments (ED). The basic objectives of this study were to assess the diagnostic performance of PCT for distinguishing between viral and bacterial infections and for the early detection of invasive bacterial infections in febrile children between 1 and 36 months old comparing it with C-reactive protein (CRP) and to evaluate the utility of a qualitative rapid test for PCT in ED. Methods. Prospective, observational and multicenter study that included 445 children who were treated for fever in pediatric ED. Quantitative and qualitative plasma values of PCT and CRP were correlated with the final diagnosis. To obtain the qualitative level of PCT the BRAHMS PCT-Q rapid test was used. Results. Mean PCT and CRP values in viral infections were 0.26 ng/ml and 15.5 mg/l, respectively. The area under the curve obtained for PCT in distinguishing between viral and bacterial infections was 0.82 (sensitivity, 65.5%; specificity, 94.3%; optimum cutoff, 0.53 ng/ml), whereas for CRP it was 0.78 (sensitivity, 63.5%; specificity, 84.2%; optimum cutoff, 27.5 mg/l). PCT and CRP values in invasive infections (PCT, 24.3 ng/ml; CRP 96.5 mg/l) were significantly higher than those for noninvasive infections (PCT, 0.32 ng/ml; CRP, 23.4 mg/l). The area under the curve for PCT was 0.95 (sensitivity, 91.3%; specificity, 93.5%; optimum cutoff, 0.59 ng/ml), significantly higher (P < 0.001) than that obtained for CRP (0.81). The optimum cutoff value for CRP was >27.5 mg/l with sensitivity and specificity of 78 and 75%, respectively. In infants in whom the evolution of fever was <12 h (n = 104), the diagnostic performance of PCT was also greater than that of CRP (area under the curve, 0.93 for PCT and 0.69 for CRP; P < 0.001). A good correlation between the quantitative values for PCT and the PCT-Q test was obtained in 87% of cases (kappa index, 0.8). The sensitivity of the PCT-Q test (cutoff >0.5 ng/ml) for detecting invasive infections and differentiating them from noninvasive infections was 90.6%, with a specificity of 83.6%. Conclusions. PCT offers better specificity than CRP for differentiating between the viral and bacterial etiology of the fever with similar sensitivity. PCT offers better sensibility and specificity than CRP to differentiate between invasive and noninvasive infection. PCT is confirmed as an excellent marker in detecting invasive infections in ED and can even make early detection possible of invasive infections if the evolution of the fever is <12 h. The PCT-Q test has a good correlation with the quantitative values of the marker.

Clinical data in children with meningococcal meningitis in a Spanish hospital

Neisseria meningitidis is the main cause of bacterial meningitis in Spain. Of the 213 children included in this study with meningococcal meningitis, 7 died. Mortality was linked to a shorter time from the first symptom to diagnosis (mean time for fatal cases was 9.5 h, mean time for survivors was 19h, p= 0.034), to deteriorated consciousness (DC) (mortality rate (MR) with DC = 6/87, MR without DC = 1/124, p= 0.02) and to shock (MR with shock = 5/7, MR without shock = 2/206, p < 0.0001). Previous treatment reduced the yield from blood culture (36/54 versus 45/137, p < 0.0001). Positivity in both Gram stain (GS) and cerebrospinal fluid (CSF) culture increased with longer duration of symptoms (mean GS+= 25h, GS‐= 16h, p= 0.004; CSF+= 20h, CSF‐= 12h, p= 0.001), and blood culture (BC) gave more positive results when carried out earlier (mean BC+= 14 h, BC = 24 h, p < 0.001). Reduced susceptibility to penicillin was seen in 34% of the strains, and rapidly evolving forms were responsible for most of the deaths; reduced susceptibility was more frequent among strains responsible for death or sequelae (9/15 = 60%) as compared with the more harmless strains (69/ 215 = 32%) (p= 0.04). The progressive reduction of susceptibility to penicillin indicates that it should be replaced by a third‐generation cephalosporine.

Procalcitonina para el diagnóstico precoz de infección bacteriana invasiva en el lactante febril

Antecedentes La procalcitonina es un parametro nuevo de infeccion bacteriana. Por su vida media mas corta y ascenso masprecoz puede ofrecer ventajas respecto a la proteina C re-activa (PCR). Objetivo Evaluar la rentabilidad diagnostica de la procalcitonina en la deteccion precoz de infeccion bacteriana invasiva en el lactante febril frente a la PCR. Material y metodo Estudio prospectivo y observacional realizado en la sec-cion de urgencias entre enero de 1998 y febrero de2000 que incluyo lactantes entre 1 y 36 meses, atendidospor fiebre, en los que debieron practicarse determinacio-nes analiticas sanguineas. Se evaluaron los valores plas-maticos de procalcitonina y PCR y se correlacionan con el diagnostico final. Se elaboran las curvas ROC (receiva ope-rating characteristic) para ambos marcadores. Resultados Se incluyeron en el estudio 100 lactantes con edad media de 8,8 meses (DE, 7,59) distribuidos en 4 grupos de 25 pacientes (infeccion viral, bacteriana localizada, bacteriana invasiva y grupo control). Los valores medios de procalcitonina y PCR en infecciones invasivas (procalcitonina, 14,45 ng/ml [DE, 27,95]; PCR, 95,10 mg/l [DE, 33,04]) fueron significativamente superiores a las no invasivas (procalcitonina, 0,27 ng/ml [DE, 0,19]; PCR, 25,67 mg/l [DE, 33,04]) pero la rentabilidad diagnostica de procalcitonina fue mayor. El area bajo la curva para procalcitonina fue de 0,95 (DE, 0,03), superior a la obtenida para PCR (0,81 [DE, 0,05]) (p 0,4 ng/ml (sensibilidad 95,5 %, especificidad 86,4 %) y para PCR en > 42,9 mg/l con sensibilidad 75 % y especificidad 81,8 %. En los lactantes con fiebre inferior a 12 h (n = 30), el area bajo la curva para procalcitonina ha sido 0,90 (DE, 0,06), tambien superior a la PCR (0,64 [DE, 0,11]) (p 0,4 ng/ml (sensibilidad, 90 %; especificidad, 94 %) y para PCR es > 26,6 mg/l (sensibilidad, 60 %; especificidad, 77,8 %). Conclusion La procalcitonina es un marcador de mayor rentabilidad diagnostica que la PCR en la deteccion de infeccion bacteriana invasiva en el lactante febril incluso de forma precozen evoluciones inferiores a 12 h.

Calidad de la prescripción antibiótica en un servicio de urgencias pediátrico hospitalario

INTRODUCTION Adequate antibiotic prescribing in Paediatric Emergency Departments (PEDs) is a necessity due to the high number of patients consulting for infectious diseases. The aim of this study was to evaluate the antibiotic prescription quality in a PED. MATERIAL AND METHODS Retrospective study of patients attending a PED and diagnosed with acute otitis media, pharyngotonsillitis or community-acquired pneumonia during 2008. A random sample of 100 cases for each disease was selected. The parameters employed for assessing the prescribing quality were: illness subject to being treated with antibiotics, adequate antibiotic, dosage, interval of administration and length of treatment. An error in any of these parameters was considered an inappropriate prescription. The appropriateness of the antibiotic prescriptions was assessed based on the recommendations described on our hospital protocols. RESULTS Antibiotics were prescribed to 219 patients (73%). Therapy was considered to be inappropriate in 67 children (22.3%). Unnecessary treatment was indicated in 15 cases (6.8%) and in 4 patients (2%) the antibiotic selected was incorrect. Antibiotic was not prescribed to one patient subject to being treated (1.2%). The treatment length was wrong in 22 cases (11.5%), inappropriately short in all of them, the interval of administration in 20 (10.1%) and dosage in 13 (6.5%). CONCLUSIONS The use of antibiotics was appropriate for the diseases analysed, particularly as regards to the indication and antibiotic selection. The length of the treatment was the aspect found to be most deficient. Some important measures should be undertaken in order to improve antibiotic prescription quality.

Intoxicaciones voluntarias como intento de suicidio

Antecedentes La intoxicacion voluntaria como intento de suicidio es actualmente un problema importante entre la poblacion adolescente. La tentativa de suicidio es la urgencia psiquiatrica mas frecuente en la adolescencia. Presentamos nuestra experiencia sobre intoxicaciones voluntarias durante un periodo de 2 anos. Material y metodos Estudio retrospectivo y descriptivo de los pacientes ingresados por intoxicaciones voluntarias desde enero de 1996 hasta diciembre de 1997. Se analizan: sexo, edad y hora de la intoxicacion, antecedentes de habitos toxicos, controles psiquiatricos o intoxicaciones previas, tipo y obtencion del toxico utilizado, sintomatologia presentada en el momento de acudir a urgencias, actitud terapeutica y exploraciones complementarias mas utilizadas, y dias de estancia hospitalaria. Resultados Durante el periodo de estudio ingresaron 46 pacientes. La edad mediana fue de 15,6 anos, siendo mas frecuente en el sexo femenino (40 casos) (87%). Un 60,9% (28 casos) habia sido controlado previamente en algun servicio de psiquiatria. El toxico utilizado fue de naturaleza farmacologica, y es obtenido en 38 pacientes (82,6%) del botiquin del hogar. En 22 casos (47,8%) se trata de intoxicacion multiple. El 13% (6 pacientes) requirio hospitalizacion en cuidados intensivos. La duracion media de la estancia hospitalaria fue de 3 dias. Comentarios Las intoxicaciones voluntarias como intento de suicidio representan un problema importante entre la poblacion adolescente, y sobre todo entre las adolescentes de sexo femenino. La identificacion de la poblacion de riesgo seria la mejor medida preventiva, constituida por adolescentes, de sexo femenino en su mayoria, con depresion, trastornos de la conducta alimentaria o tentativas de suicidio anteriores.

Registro de traumatismos craneoencefálicos leves: estudio multicéntrico de la Sociedad Española de Urgencias Pediátricas

OBJECTIVE To determine management practices of minor head trauma in children evaluated at Spanish Hospital Emergency Departments and to determine patient variables associated with intracranial injury. METHODS Multicenter and prospective study during 18 months in 9 hospitals in Spain. Patients up to the age of 18 years with minor head trauma (Glasgow Coma Scale score higher than or equal to 13 on admission), treated in Emergency Departments and with a maximum onset of 72h since the traumatism, were included in the study. RESULTS A total of 1070 patients were studied with a median age of 2.4 years (p25-75 0.9-6.4 years); 61.2% were male. The median time between head trauma and medical consultation was 1 hour (p25-75 0.6-2.5h). Skull X-rays were performed on 64.5% of the children and a head CT scan on 9%; 91.4% of X-ray and 84.4% of CT were normal. The prevalence of intracranial injury was 1.4% (95% CI: 0.8-2.3). Twenty-five point three percent of the patients were admitted; 4 (3.7%) required neurosurgical intervention during admission. None of the patients died. Multiple logistic regression analysis identified loss of consciousness (OR 4.2, 95% CI: 1.1-17; P=0.045), neurological deterioration (OR 8.8, 95% CI: 2.1-37.6; P=0.003) and cephalhaematoma (OR 14.6, 95% CI: 4.9-44; P <0.001) as independent predictors of intracranial injury. CONCLUSIONS The combination of clinical parameters allows selection of patients with minor head trauma who need complementary explorations. In consequence, the routine use of skull X-ray in their initial evaluation is unnecessary.

Púrpura fulminante posvaricelosa

Purpura fulminans (PF) is an infrequent complication of varicella characterized by the progressive development of purpuric or painful ecchymotic lesions associated with biochemical alternations typical of consumption coagulopathy. Activation of coagulation is due to a marked and prolonged decrease in protein S, which is probably secondary to the formation of antiprotein S antibodies. The mechanism responsible for the synthesis of these autoantibodies is unknown. We present three cases of postvaricella PF and review the clinical and biochemical characteristics of this entity, as well as current diagnostic and therapeutic recommendations.

Neumonía adquirida en la comunidad: tratamiento de los casos complicados y en situaciones especiales. Documento de consenso de la Sociedad Española de Infectología Pediátrica (SEIP) y Sociedad Española de Neumología Pediátrica (SENP) ◊

The incidence of community-acquired pneumonia complications has increased during the last decade. According to the records from several countries, empyema and necrotizing pneumonia became more frequent during the last few years. The optimal therapeutic approach for such conditions is still controversial. Both pharmacological management (antimicrobials and fibrinolysis), and surgical management (pleural drainage and video-assisted thoracoscopic surgery), are the subject of continuous assessment. In this paper, the Spanish Society of Paediatric Infectious Diseases and the Spanish Society of Paediatric Chest Diseases have reviewed the available evidence. Consensus treatment guidelines are proposed for complications of community-acquired pneumonia in children, focusing on parapneumonic pleural effusion. Recommendations are also provided for the increasing population of patients with underlying diseases and immunosuppression.

Criterios de adecuación de ingresos en urgencias pediátricas

Sr. Editor: La calidad asistencial hoy por hoy es uno de los temas de actualidad dentro del campo de la sanidad. En todos los estamentos organizativos existe la preocupación generalizada de la optimización de los recursos económicos, de tal manera que se intenta reducir el gasto económico sanitario, pero evidentemente sin reducir la calidad de los servicios prestados ni la accesibilidad al sistema sanitario por parte de los usuarios. Por este motivo pensamos que una manera de reducir el gasto sanitario sería actuar sobre los ingresos que son considerados inadecuados, es decir, detectarlos y proponer soluciones alternativas a ese ingreso. ¿Cómo se puede considerar un ingreso hospitalario como inadecuado? Pues bien, en el año 1989, Kreger et al1 publicaron la validación del Pediatric Appropriateness Evaluation Protocol (pAEP), instrumento objetivo y útil para identificar a aquellos pacientes que pueden beneficiarse de una alternativa al ingreso hospitalario. En España, Casanova2 valida este instrumento para nuestra población en 1999. Posteriormente se han realizado estudios y aplicaciones del instrumento en varias publicaciones, que demuestran un porcentaje de ingreso inadecuado en diferentes centros hospitalarios de nuestro país, comprendido entre el 7,9 y el 27,8%3-7. El pAEP consiste en una escala con criterios objetivos, explícitos e independientes del diagnóstico, para evaluar el ingreso y la estancia hospitalarios. El apartado que hace referencia a la evaluación del ingreso pediátrico consta de 22 ítems, y tiene en cuenta criterios referentes a la situación clínica del paciente y a los servicios clínicos prestados. Además dispone de un listado de causas por las que el paciente en cuestión no cumple ningún criterio de ingreso adecuado; es decir, el caso se considera como ingreso inadecuado (tabla 1). A continuación presentamos nuestros resultados. Son datos preliminares de un estudio que se está realizando en nuestro hospital, aplicando el pAEP a la población hospitalaria. Se trata de un estudio prospectivo, con un período de estudio entre mayo y septiembre de 2003. La población de estudio incluye a todos los pacientes hospitalizados, pero se excluye a los ingresados en el Servicio de Psiquiatría y en la Unidad de Cuidados Intensivos, así como lactantes con edad inferior a 6 meses. El día de revisión se elige al azar, 5 días al mes y se aplica a escala al 10% de los pacientes que se encuentran en el hospital ese día; de esta muestra se evalúa a los pacientes ingresados a través del Servicio de Urgencias. Se considera ingreso adecuado aquel que cumple uno de los 22 ítems de adecuación del ingreso pediátrico del pAEP. La muestra consta de 147 casos, de los cuales 77 pacientes ingresan desde el Servicio de Urgencias y 70 resultan programados. El 58,4% de los ingresos urgentes son niños y la franja de edad con mayor incidencia está entre 1 y 4 años. El 14,3 % (11 pacientes) de los ingresos procedentes de Urgencias son inadecuados, es decir, no cumplen ninguno de los 22 ítems del pAEP. Al distribuir los ingresos procedentes de Urgencias por especialidades pediátricas, se observa que en el Servicio de Cirugía, 3 de 22 casos son considerados inadecuados; en Cirugía Ortopédica y Traumatológica, 2 de 14, y en Pediatría 5 de 23 pacientes (21,7%). En el resto de especialidades el porcentaje de inadecuación es mucho menor. Al analizar la causa de la inadecuación de ingreso se observa que el ítem “todas las necesidades diagnósticas y terapéuticas pueden ser realizadas como paciente externo” es el más frecuente (64% de casos). Con estos resultados se comprueba que el porcentaje de inadecuación obtenido se corresponde con la mediana de los estudios publicados, y que la causa más frecuente de ingreso inadecuado se debe a procedimientos y tratamientos que se pueden realizar de forma ambulatoria. Para solucionar este problema se propone el establecimiento de estructuras de soporte a Urgencias, como son las consultas de atención rápida. Queremos remarcar que la utilización de instrumentos como el pAEP permite detectar casos de inadecuación de ingresos. Dado que en nuestro caso la principal causa de inadecuación proviene de la realización de pruebas complementarias que podrían programarse de forma ambulatoria, la creación de vías alternativas para realizarlas en un breve período y de forma rápida puede verse reflejada en una disminución de la tasa de ingresos inadecuados, lo cual implicaría una optimización en la utilización de los recursos económicos. Una aplicación periódica del pAEP puede sernos útil como control de la calidad de nuestros ingresos.

Estudio multicentrico sobre factores de riesgo de lesiones en accidentes de automovil

INTRODUCTION Traffic accidents are the main cause of death in children between 2 and 14 years in developed countries. We analysed their clinical repercussions, epidemiological characteristics, use and suitability of Child Restraint Systems (CRS) and its correlation with the type of injuries in children less than 12 years old. MATERIAL AND METHODS Multicentre descriptive prospective study. The following data was collected: personal details of the victims and the type of accident, use and suitability of the CRS, classification of injuries according to location and severity, need for hospitalisation, medical treatment received, use of Emergency Services and final destination of the injured. RESULTS A total of 366 patients were studied, with a sex ratio of 1:1 and a mean age of 6 years. Of these, 69.7% had some injury (slight 92.3%). A total of 81.1% affected the head and neck, and 77.9% used some type of CRS (suitable only in 55.7%). CRS were used more in >6 year olds (27.1%-P<0.001). Driving long distances (odds ratio 6.7) and not using a suitable CRS (odds ratio 3.7) were associated with the severity of the injuries. The age of the patients and the position within the automobile were not related. All the patients with a Glasgow less than 8 and all the deceased were using an unsuitable CRS. The hospitalization rate was 8.7% and the mortality rate at 24h was 0.8%. CONCLUSIONS An important percentage of the injured children do not use suitable child restraint systems. Non-use of a CRS or its inadequate use is a risk factor of morbidity in the traffic accidents in childhood.